Supplemental History From

Have you had the following?

	Yes	No
Joint replacement
Complications with joint replacement
Pins or plates placed during surgery
Artificial bones

If yes to any of the above, please list name and telephone number of Orthopedic Surgeon:
Name
Phone number

Have you ever been diagnosed with the following conditions?

	Yes	No
A history of endocarditis
Heart murmur
Mitral Valve prolapse
Congenital heart disease/defect
Heart surgery/repair of any kind including valve repair, shunts, transplant, pacemaker
Heart attack
Stroke
Rheumatic Heart Disease or Rheumatic Fever
Scarlet fever

If yes to any of the above, please list name and telephone number of Cardiologist:
Name
Phone

Are you receiving chemotherapy and have a central venous catheter

	Yes	No
Any organ transplant
Breast augmentation with implants
Any implant (other than to replace teeth)

If yes to any of the above, please list name and telephone number of Physician:
Name
Phone number
Are you taking Bisphosphonate medication to treat Osteoporosis?

YesNo
Any allergies, including metal, latex, and/or drugs?

YesNo
If yes, please list allergies:
Any other medical problems:
Signature of Patient/Parent or Guardian if over 18

Powered by Jotform SignClear
Date

MonthDayYear
Date
Address

Home Address

Street Address Line 2

CityState

Zip
Phone
Email Address
example@example.com
Signature

Powered by Jotform SignClear
Should be Empty:

Medical History Supplement for Antibiotic Prophylaxis